General anesthesia

Dr.Abdi Farah Taano

Anesthesiologist,Emergency and ICU
 Anesthesia- division
Local-
regional anesthesia

General- anesthesia interact

with whole body, function of
central nervous system is
depressed:
– Intravenous
– Inhalation (volatile)
– Combined, balanced
 TIVA
Total Intra Venous Anaesthesia

VIMA
Volatile Induction and Maintain
Anaesthesia

 Combined, balanced
Parts of general anesthesia

 Hypnosis- pharmacological sleep,

reversable lack of consciousness
 Analgesia-pain management
 Areflexio-lack of reflexes
 Relaxatio musculorum- muscle
relaxation, pharmacological reversable
neuromuscular blockade
 Parts of general anesthesia must
be in balance between:

Hypnosis (anesthesia) Analgesia

Lack of reflexes (muscle relaxation)

Stages of general
anesthesia

• Stadium analgesiae (analgesia and

sedation stage)
• Stadium excitationis (excitation stage)
• Stadium anaesthesiae chirurgicae
(anesthesia for surgery)
• Stadium paralysis respirationis
(intoxication, respiratory arrest)
 I. Analgesia stage
• Patient consciouss
• Spontaneus respiration
• Reflexes present
• Possible small surgery procedures like dressing change in burns
II. Excitation stage
• Possible uncontrolled movements, vomitings
• Increase in respiratory rate

III. Anesthesia for surgery

• It begins with lack of lid reflex
• Airway opening necessary
• Possible surgery
• Possible endotracheal intubation
 Methods of general anesthesia
CIRCLE SYSTEM
*HIGH FLOW
FRESH GAS FLOW > 3 l/min.
*LOW FLOW
FGF ok. 1l/min.
*MINIMAL FLOW
FGF ok. 0,5 l/min.

Stages of general anesthesia

• Introduction to anesthesia (induction)
• Maintaining of anesthesia (conduction)
• Recovery from anesthesia
Anesthesia agents
 Inhalation anesthetics (volatile anesthetics) -
gases : N2O, xenon - Fluids (vaporisers)
 Intravenous anesthetics - Barbiturans :
thiopental - Others : propofol, etomidat
 Pain killers - Opioids: fentanyl, sufentanil,
alfentanil, remifentanil, morphine - Non
Steroid Anti Inflamatory Drugs: ketonal,
paracetamol
 Relaxants - Depolarising : succinilcholine -
Non depolarising : atracurium, cisatracurium,
vecuronium, rocuronium
 adiuvants -benzodiazepins: midazolam,
diazepam
Volatile vs
intravenous
anesthesia
 Mechanism of action of inhaled anesthetics
 Reaction depends on concentration. This
depends on alveolar (first compartment), blood
and brain (central compartment) concentration
(third compartment- other tissue like muscles,
fat accumulation effect):
– Minute ventilation
– Lung blood perfusion
– Solubility in tissues

MAC-minimal alveolar concentration

Concentration in which 50% of anesthetised patients do not
react on skin incision
Inhalation agents

Division of inhalation agents

1.Gases:
• N2O – old, weak, used as adiuvant
• Xenon – lately introduced
2. Vapors (fluids):
• Halothan
• Enfluran
• Isofluran
• Sevofluran
• Desfluran
Features of ideal volatile
anesthetic
 Not disturbing smell
 Fast acting, titrable
 Low solubility in blood- fast transport to
brain
 Stable when stored, not reacting with other
chemicals
 Non- flamable, non- explosive
• Low methabolism in body, fast elimination,
no accumulative effect
 No depressing effect on circulatory and
respiratory systems
 Nitrous oxide
• Old ,Weak.
Halothan
• Used for many years with good effect
• First non-flamable volatile fluid anesthetic
• MAC high
• Reduces the blood pressure and frequently
decreases the pulse rate and depresses
respiration.Potent brochodilator.It´s not hepatotoxic
in children.Relaxes skeletal and Uterine
muscles.Suitable in pediatric inhalation induction.
• Hepatotoxic adult,not readminister intervals of less
than 2-3 weeks
• Now-a-days used only in pediatric anesthesia,but
sevoflurane is the best.
 Isofluran
• Disturbing smell,cheap.
• May interact with heart contractivity
• Increases relaxation of muscles
Desfluran
• Very disturbing smell- can not be used for
VIMA .Rapid onset and recovery. Decreases
vascular resistance.
• Is not methabolised
• Very fast acting
• May be used for one-day surgery
• Expensive, difficult to store (boiling temp.
about 20 C)
• Modern and widelly used
Sevofluran
• Not disturbing smell- may be used for
VIMA
• Low solubility in blood- fast acting
• Does not disturbs airway
• May depress circulatory system
• Methabolised to Compound A- may be
renal toxic (but not confirmed in humans)
• May be used in one-day surgery
• Modern, and more and more widely used
volatile anesthetic
Intravenous anesthesia
TCI (target controlled infusion)
 TCI is an infusion system which allows the
anaesthetist to select the target blood
concentration required for a particular effect

 It allows to control depth of anaesthesia by

adjusting the requested target concentration
 Instead of setting ml/h or a dose rate
(mg/kg/h), the pump can be programmed
to target a required blood concentration.

 Effect site concentration targeting is now

included for certain pharmacokinetic
models.

 The pump will automatically calculate how

much is needed as induction and
maintenance to maintain that
concentration.
THIOPENTAL

 Old, one of the first used intravenous anesthetics

 Used Induction of anesthesia and anticonvulsant.

 Machanism: Enhancess the ability of GABA to activate GABA-A

receptors.

 Kinetics:
➢ Duration :10-60min.
➢ Elimination half-life: 15h.
➢ Hepatic metabolism.
➢ Renal excretion.

 Depressing effect on circulatory system

Ketamine
Only intravenous anesthetic which has
good analgesia effect

Does not depress circulatory nor respiratory

function

Used in children, and in emergency and

disaster medicine

Gives night mare dreams in adult patients

Propofol
Very good anesthetic for induction and
maintaince of anesthesia with no
accumulation effect
 Titrable
 May be used in short procedures –
titrated do not effect circulatory and
respiratory system in important manner
 Good for sedation, brain protecting effect
 May be used in TCI
 Opioids

 fentanyl, alfentanil, sufentanil,

remifentanil
 May be used for induction and maintain
of anesthesia in repeated bolus or
continuous infusion technique
 Sedative effect
 In high doses may be used alone for so
called opioid anesthesia- formerly used in
cardioanesthesia- very stable circulatory
effect
 Complications of use

 Respiratory depression
 Muscle rigidity in high doses
 Post-Operative Nausea and
Vomitings
 Accumulation effect after prolonged
administration (except for
remifentanil)
 Remifentanil

 T1/2 3-5 min

 Methabolised by non-specific tissue

esterases- methabolism is not
altered by renal or liver function

 No accumulation effect after

prolonged
BENZODIAZEPINES

Used in anesthesia:
Diazepam
Midazolam

Used as adiuvants for premedication

 MUSCLE
RELAXANTS
Division of relaxants depending on mechanism
of action
 1.nondepolarising-
combine with receptor for Ach like antagonists-
they are fake mediators
do not cause muscle contractation but block
access to receptors for Ach

 2.depolarising-
they combine with receptors for Ach and cause
contractation of muscle but they stay
connected with receptor blocking access to it
for Ach.
They act like agonists.
 Division of non-depolarising relaxants due
to Chemical structure:

 AMINOSTEROIDS
 Pancuronium
 Rocuronium ( Esmeron )
 Mivacurium( Mivacron )
 Cisatracurium( Nimbex )
 Atracurium
 Division of nondepolarising relaxants
due to time of action:

 Short acting < 3 min: still searching

 Midle time <60 min: mivacurium,

atracurium, cisatracurium,
rocuronium, vecuronium

 Long acting > 60 min: pancuronium.

 Atracurium
 Elimination non-enzymatic, independent of renal and liver
function, Hoffman elimination- hydrolisis

 Releases histamine

 Acts about 30 min

Cisatracurium

 One of stereoisomers of atracurium,

 Do not release histamine

 Acts about 60 min

 Rocuronium

 Fast acting- time to 100% supresion 60 sec.

 Do not release histamine
 Acts about 60 min
 Is methabolised in liver- disfunction of liver may
alter elimination
 Mivacurium
 Releases histamine
 Acts about 15-20 min – used for short
procedures
 Methabolised by plasma esterases
 Reverse of neuromuscular blockade
 Neostigmine, piridostigmine- blockers of
acetylocholinesterase
 Must be given together with atropine to avoid
bradycardia caused by activation of perisympatic
system
 Depolarising agents
 Only one: succinilocholine –
 It is methabolised by pseudocholinesterase -
Causes many complications, has many
contraindications –
 Indications: Rapid sequence induction: full
stomach, suspected difficult intubation because it
acts very fast < 45 seconds and short < 3 min
 Complications of general
anesthesia
 Respiratory: residual relaxants/opioids
action

 Circulatory

 Neurological: residual
anesthetics/opioids action

 Post-Operative Nausea and Vomitings

Mortality connected with anesthesia

 0,05 - 4/10000 GA
 2 2 - 16 % of surgical surgical patients
 80 % is caused by human mistakes

Major causes of deaths

Airway obstruction
Difficult and unefficient intubation
Insufficient ventillation
 Other causes of mortality and morbidity

 Anoxia
 Haemodynamic instability
 Aspiration Pneumonia
 Toxity of drugs
 Anaphylaxia and and drug interations
Thanks